Detail-oriented and highly organized medical billing specialist with 8 years of experience in medical coding, insurance claims processing, and revenue cycle management. Proficient in ICD-10, CPT, and HCPCS coding, with a deep understanding of HIPAA compliance and medical terminology. Adept at reducing claim denials and improving reimbursement rates through meticulous documentation and follow-ups. Committed to maintaining accurate billing records and optimizing financial performance for healthcare providers.
Josefina Herera Cerilles State College
Cum Laude - 1.56 GWA
Insurance Verification Specialist
* Verify patient insurance coverage and eligibility before medical services.
* Contact insurance companies to confirm policy details, copayments, deductibles, and out-of-pocket costs.
* Ensure accurate documentation of insurance information in Electronic Health Records (EHR) systems.
* Communicate coverage details, limitations, and financial responsibilities to patients.
* Identify and resolve discrepancies in patient insurance information.
* Work with providers and patients to clarify benefits, exclusions, and coordination of benefits (COB).
* Monitor and update changes in insurance policies and payer requirements.
* Collaborate with billing teams to streamline claim submissions and reduce denials.
* Maintain compliance with HIPAA regulations and protect patient confidentiality.
* Keep detailed records of verification processes for audits and reporting.
* Follow up on pending verifications to ensure timely approvals and payments.
* Train and educate staff on insurance verification procedures and best practices.
Prior Authorization Specialist
* Submit prior authorization requests for medical procedures, medications, and treatments.
* Contact insurance companies to determine medical necessity requirements and pre-approval criteria.
* Gather and submit necessary clinical documentation for authorization approval.
* Track authorization requests and follow up on pending or denied approvals.
* Communicate authorization status and coverage limitations to healthcare providers and patients.
* Work closely with physicians and medical staff to ensure timely submission of authorization requests.
* Appeal denied authorizations and provide supporting documentation for reconsideration.
* Update patient records with authorization details, approval numbers, and expiration dates.
* Stay informed about insurance policies, payer guidelines, and regulatory changes.
* Maintain HIPAA compliance and ensure patient data security.
* Coordinate with billing and coding teams to prevent claim rejections due to missing authorizations.
* Monitor trends in authorization denials and implement process improvements to reduce delays.
Credentialing Specialist
* Collect and verify healthcare provider credentials, including licenses, certifications, and education.
* Submit and maintain provider applications for enrollment with insurance networks and payers.
* Ensure compliance with state, federal, and payer-specific credentialing requirements.
* Track credentialing and re-credentialing deadlines to avoid service interruptions.
* Maintain accurate and up-to-date provider profiles in credentialing databases.
* Respond to payer requests for additional documentation or clarification.
* Conduct background checks and confirm provider standing with licensing boards.
* Manage contracts and agreements between providers and insurance companies.
* Ensure National Provider Identifier (NPI) and Tax ID details are correctly linked to provider accounts.
* Work closely with medical staff, administrators, and insurers to expedite the credentialing process.
* Monitor payer network participation and maintain documentation of contract terms.
* Assist providers with Medicare and Medicaid enrollment processes.
Medical Billing Specialist
* Review and submit medical claims to insurance companies for reimbursement.
* Verify patient insurance information before claim submission.
* Ensure accurate coding of diagnoses and procedures using ICD-10, CPT, and HCPCS codes.
* Follow up on unpaid claims and resolve payment discrepancies.
* Process claim denials, file appeals, and submit necessary documentation for reconsideration.
* Reconcile payments and post insurance and patient payments in billing systems.
* Communicate with insurance companies to clarify claim status and coverage issues.
* Assist patients with billing inquiries and explain their financial responsibilities.
* Maintain compliance with HIPAA regulations and insurance billing policies.
* Work with collections to follow up on outstanding patient balances.
* Generate financial reports and track revenue cycle performance.
* Stay updated on industry changes, including payer requirements and coding updates.
* Train new hires regarding product knowledge (eligibility, benefits, prior authorization, COB, claim status/denials, etc.)
* Monitor agent’s behavior and performance for scorecard/metrics.
* Conduct team meetings for necessary update
* Provide coaching regarding quality errors, action plans and achievement.
Do supervisory call if needed.
Specializes process insurance claims, manage payments, and ensure accurate reimbursement while following regulations.
Handling diverse type of people and making sure to deliver world class customer service.
Obtain prior approvals from insurance providers, ensuring medical procedures are covered and reimbursed.
Verify and manage provider credentials, ensuring compliance with insurance and regulatory requirements.
Verifying patient insurance coverage, confirm benefits, and ensure accurate claims processing for providers.